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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 2  |  Issue : 2  |  Page : 140-146

Prevention and control of cardiovascular diseases in India needs a strengthened and well-functioning primary health care system: A narrative review


1 Department of Health Systems, World Health Organization India Country Office, New Delhi, India
2 Department of Community Medicine, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
3 Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
4 Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
5 The Heart Clinic, Vasai-Virar, Maharashtra, India
6 Department of Anthropology and Sociology, Graduate Institute of International and Development Studies, Geneva, Switzerland

Date of Submission20-Sep-2020
Date of Decision03-Dec-2020
Date of Acceptance09-Feb-2021
Date of Web Publication30-Aug-2021

Correspondence Address:
Dr. Chandrakant Lahariya
B-7/24/2, First Floor, Safdarjung Enclave Main, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_166_20

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  Abstract 


This article reviews the ongoing initiatives to prevent and control cardiovascular diseases (CVDs) and non-communicable diseases (NCDs) in India and analyses the role of primary health care (PHC) system. The authors note that in last 2 decades, there has been increasing policy recognition of the challenges posed by CVDs and NCDs in India. The review of ongoing government health program in India indicate that while the interventions to tackle CVDs and NCD have also been launched and scaled up, a majority of these initiatives continue to be delivered through district or sub-district levels. Though, there has been plans, the scale up through PHC system is at early stage only. There is sufficient scientific evidence that the effective prevention and control of CVDs need accessible health services and a series of public health interventions through strengthened PHC system. There are learnings from COVID-19 pandemic response in India (in areas such as private sector engagement, effective enforcement of health regulation, community engagement and the use of tele-consultations), which can be useful. The authors conclude that a strengthened and well-functioning PHC system can ensure increased access to CVD and NCD services. As India plans to scale up ongoing health programs and launch a few new initiatives, the learnings from the past, documented in this paper, could be useful. These steps would help India to accelerate progress towards universal health coverage.

Keywords: Ayushman Bharat Program, COVID-19, cardiovascular diseases, health and wellness centres, India, primary health care, Pradhan Mantri Atma Nirbhar Swasth Bharat Yojana, universal health coverage


How to cite this article:
Lahariya C, Mishra S, Daniel RA, Bhadoria AS, Mishra DK, Smith RD. Prevention and control of cardiovascular diseases in India needs a strengthened and well-functioning primary health care system: A narrative review. J Med Evid 2021;2:140-6

How to cite this URL:
Lahariya C, Mishra S, Daniel RA, Bhadoria AS, Mishra DK, Smith RD. Prevention and control of cardiovascular diseases in India needs a strengthened and well-functioning primary health care system: A narrative review. J Med Evid [serial online] 2021 [cited 2021 Sep 25];2:140-6. Available from: http://www.journaljme.org/text.asp?2021/2/2/140/324974




  Introduction Top


The non-communicable diseases (NCDs) contribute to nearly two-thirds of the total burden of diseases in India.[1],[2],[3] The cardiovascular diseases (CVDs) account for nearly half of total NCD deaths and around 28% of all deaths in the country.[3],[4] This review article analyses how the ongoing and proposed initiatives to strengthen the primary health-care (PHC) system can contribute to prevention and control of CVDs.


  Materials and Methods Top


The desk review of published literature was conducted. The websites of the ministries and departments of health and family welfare of the union and the state governments in India as well as the online databases including Medline/PubMed, Scopus, Embase and Google Scholar were searched. The desk review was supplemented by the hand search of the additional literature in libraries. The desk review was done independently by two authors (CL and SM). The keywords of CVDs, NCDs, Primary Health care and India were used for search in identified databases in various combination. The initial literature review was done from January to August 2019, which was updated in July 2020.

Epidemiology of cardiovascular diseases in India

India has witnessed a rapid transition in CVD risk factors in the past two decades. As an example, the prevalence of hypertension in urban settings has remained nearly stagnant yet relatively high at 28% to 32%, whereas it has increased in rural population[4] from around 10%–12% in the 1990s to 22%–25% in 2016.[4],[5] A similar upward trend in the prevalence of obesity has been documented.[6] The upward trends in tobacco usage, sedentary lifestyle, abdominal obesity and other metabolic risk factors have contributed to the increased burden of CVDs in India. The CVDs and NCDs, are at times incorrectly considered as urban only phenomenon. The recent, epidemiological studies have found that the prevalence of risk factors and disease burden of NCDs and CVDs in rural areas is only marginally lower (than the urban settings) and is increasing at a rapid pace. This situation has evolved alongside the better scientific understanding of the risk factors for NCDs and CVDs, providing opportunities to develop, design and implement a range of health interventions. The modifiable risk factors underscore the scope to reduce the burden of CVDs in India [Table 1].
Table 1: Risk factors of cardiovascular diseases

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Evolution of key programmes to tackle non-communicable diseases in India

In the last few years, there has been a series of programmatic interventions to tackle the CVDs in India [Box 1]. One of the key initiatives, the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS), was launched in January 2010.[7] The programme proposed and adopted opportunistic screening approach and has been implemented on a hub-and-spoke model.[7] Tertiary level hospitals and medical colleges serve as 'hubs,' whereas peripheral facilities are expected to function as spokes [Figure 1]. The NPCDCS aimed to deliver these services initially through district hospitals and then scaling up to sub-district level facilities. The programme focused upon increasing awareness in the community regarding NCDs and CVDs risk factors, adoption of healthy lifestyles and individual and family counselling for those initiated on treatment, for the improved compliance.[7] Nearly a decade after launch, by March 2020, NPCDCS was being implemented through 665 district NCD cells, 637 district NCD clinics and 4472 NCD clinics at community health centres (CHCs), across India.[7] The CVDs specific modifiable risk factors reduction strategies under NPCDCS and other related programmes are summarized in [Table 2].

Figure 1: Hub-and-spoke model of NPCDCS

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Table 2: Cardiovascular diseases risk factors reduction strategies at individual, family and community level

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In 2014, India became the first country in the world to adopt the World Health Organization's action plan on NCDs. The plan, termed as '25 by 25 plan for NCDs', proposes a 25% relative reduction in the overall mortality from CVDs, cancer, diabetes or chronic respiratory diseases by 2025.[8] In India, the national action plan (NAP) for prevention and control of NCDs (2017–2022) has been released. The NAP focuses on 4 priority areas of (a) integrated and multisectoral coordination mechanisms, (b) prevention and health promotion, (c) health systems strengthening and (d) surveillance, monitoring, evaluation and research.

Starting 2018 and 2019, 'Eat Right India' and 'Fit India' campaigns have been launched, which are expected to contribute to reduce the burden of NCDs and CVDs in the country.[9],[10] The SWOT analysis of ongoing key CVDs interventions is provided in [Box 2].



Two decades of evidence synthesis

India, for the last two decades, has been facing a dual burden of diseases where the communicable diseases are still a challenge, but NCDs are rapidly increasing. Considering the challenge of communicable diseases was fully well known since independence, the government health services across the country were designed mainly to tackle infectious diseases. The challenge of NCDs was not fully acknowledged till as recent as year 2002. The second national health policy (NHP) of India, released in that year, had very limited attention on NCDs.[11] Arguably, it was only after 2005, when epidemiologists and public health community generated and released additional epidemiological analyses, evidence and data, that NCDs and CVDs started getting some policy attention.[12],[13],[14]

India's third and the latest NHP was released in 2017 and acknowledged the challenge of importance of NCDs and CVDs in the country and has provided a fresh opportunity to strengthen efforts for NCD prevention and control in India.[15] India specific burden of disease report, released in late 2017, highlighted the state-specific burden of diseases and how the NCDs and CVDs are the emerging challenges.[4] These developments were followed by launch of Ayushman Bharat Programme (ABP) in February 2018.[16] The ABP had one of the two arms, named as health and wellness centres (HWCs), which aims to strengthen PHC system through augmentation of human resources and broadening of package of services, which include NCDs and CVDs services.[16],[17],[18]

The policy formulation essential but not sufficient

The vertical disease specific programmes, fragmented service delivery and the missing links in health service delivery are a few recognised challenges in health services in most low- and middle-income countries as well as in India. A weak or very limited continuum of care across the levels often results in low awareness, persistent low disease detection rates, poor use of evidence-based interventions and low rates of adherence to care.

Although various government initiatives to tackle NCDs and CVDs in India had been designed for scale up till primary health care systems, most continue to be delivered through district and sub-district level health facilities. The experience from national programmes aimed at tobacco control; AIDS control and mental health have provided learnings that if programmes are delivered through district and sub-district level facilities only, the utilisation remains sub-optimal and impact marginal. It is not surprising that NPCDCS in India had made limited impact. The preventive and promotive health interventions (also termed as public health interventions) for NCDs and CVDs can be best delivered when services are close to the people and through primary health-care facilities.

The sub-optimal functioning of government PHC system becomes a deterrent for policy makers and programme managers to rapidly expand the programme through PHC services. A study conducted in Madhya Pradesh state of India, which had assessed the readiness of health facilities, found that only 11% of PHCs were equipped and ready to treat and prevent CVDs.[19] Yet, a major responsibility to deliver preventive and promotive services is on government health sub-system as there is limited incentive to private health sector to deliver such services.[20]

India has nearly a decade of experience in the implementation of various initiatives to tackle CVDs and NCDs. Now, the HWCs initiatives under ABP is another opportunity for CVD and NCD prevention, which should be optimally utilised. As part of the expanded package of services under HWCs, the services for NCDs including CVDs have been included and there is focus upon the assured provision of preventive and promotive health services. The population-based screening (PBS) is proposed to be done and community-based assessment checklist (CBAC) is to be filled.[21] These are the opportunity to expand the CVD prevention and treatment services through PHC system, ensuring the continuity of care.

Strengthening PHC services is not the need for rural population only. The urban population in India is nearly half of the rural population; yet, a number of primary health centres in urban India are one-fifth of the PHCs in rural India.[22] While the PHC facilities in rural India need to be made functional, in urban settings, the newer PHC facilities need to be set up and the already existing facilities should be upgraded to deliver comprehensive PHC services and made functional.[23] The interest of a number of Indian states in setting up community or Mohalla clinics is another opportunity.[24] There is emerging evidence that community clinics in Indian states are making health services available and accessible to poor and marginalised, addressing health inequities.[24],[25] These clinics can also help tackle NCDs and ensure continuity of care as well. However, this will succeed only if the scale up is not 'notional' but actually make the facilities functional and the proposed services 'available' in an assured manner. It will require focused attention and oversight by the union and state governments.

In tackling the burden of CVDs and NCDs, there is need to optimise and harmonise the ongoing discourses. There is renewed focus in India on increased engagement of urban local bodies in delivery of health services. The 74th amendment in the constitution of India has assigned the responsibility of primary care and public health to the urban local bodies (ULBs). However, very few ULBs in India prioritise spending on health and delivery of the health services.[26] Of the total government spending on health, only 4% is contributed by the ULBs.[27],[28] It is time that ULBs take more responsibility in provision of health services through a stronger PHC system.

The prevention and control of CVDs and NCDs[29] can and should benefit from the learnings from COVID-19 pandemic response.[30] The need for strengthening public health services, the role of community participation and the role of effective enforcement of health regulation has been widely understood in COVID-19 pandemic response. It was the community and people who adhered to public health advices such as face masks, hand washing and physical distancing which helped in the fight against the pandemic.[28],[30] Sustaining such behavior over a longer period of time require effective public health communication. The learnings from pandemic can be used to motivate and engage people for another set of public health interventions such as healthy diet, regular physical activity, no smoking and to avoid harmful use of alcohol. If people can adhere to and follow one set of public health advice; they can also be 'nudged' to follow another set of advices. The application of learnings from COVID-19 pandemic can help in reducing the burden of NCDs and CVDs.

It can be argued that people followed public health advice when there were functioning health services such as testing and treatment for conditions for which they were expected to adhere to public health advice. It can work if the health facilities are strengthened to provide assure, timely and affordable testing and treatment services for CVDs and NCDs through government sector. That might be the right motivation for people to adhere to the preventive advice. This need to be studied further; however, there is evidence to argue that preventive and promotive advice is more likely to be adhered to, when curative and diagnostic services are functional (for same disease conditions).

Another learning from COVID-19 pandemic is that it is health-care systems and not just medical care system which is needed to tackle the ongoing 'silent pandemics' such as CVDs and NCDs as well as the pandemics due to novel pathogens. The medical care system supplemented by a stronger and well-functioning public health services make the health-care system.

In a mix health-care system such as India, the effective control of CVDs and NCDs required that both public and private sector worked together. It needs to be explored how private sector can be better engaged in preventive and promotive interventions. Considering private sector focuses upon delivery of curative and medical care services, getting them engaged in preventive and promotive services requires additional strategies and resources. The effective referral linkage – two ways and not just one direction – will help to ensure that speciality services at secondary and tertiary care are used by those who need them, and the specialist doctor's time is not consumed for caring for the conditions, which can be tackled at primary care level.

The innovations and new tools such as legalisation of tele-consultation during COVID-19 pandemic could be immensely useful platform or NCDs and CVD-related services in India. The tele-consultation approaches has been widely adopted by the private health sector in India. It holds the potential to make specialist services available through tele-consultation at rural and remote PHCs and health sub-centres. This will save resources from the government and time for the people in accessing health services. This can also partly contribute to address widespread inequities in provision of health services as well as in health outcomes.

In February 2021, a new initiative to strengthen health systems, Pradhan Mantri Atma Nirbhar Swasth Bharat Yojana, was announced in the union budget (2021–2022) of India. This programme, in addition to other components, has focus on setting up urban PHCs and strengthening rural HWC infrastructure. As part of this initiative, a total of 28,812 HWCs would be upgraded and made functional.[31] This initiative should also be explored and used to to scale up CVD and NCD services. Alongside, a provision of unconditional grant for health has been made through the fifteenth finance commission to the elected local bodies (urban local bodies and Panchayati Raj Institutions).[32],[33] A total of Rs 70,000 crore will be allocated over a period of 5 years, and in the financial year 2021–2022, Rs. 13,192 crore has been allocated. This grant is another opportunity where health programme managers of state governments need to work closely and in coordination with officials of the local bodies to use the funds for preventive, promotive and other public health interventions.[32]


  Conclusion Top


There is a dual burden of communicable and noncommunicable diseases in India. A proportion of CVDs and NCDs are preventable. The strengthening of PHC system and the provision of public health services has potential to tackle the burden of CVDs and NCDs in India. The initiatives such as HWCs under ABP and recently announced 'Pradhan Mantri Atma Nirbhar Swasth Bharat Yojana' should be used for integration and accelerated scaled up of CVDs and NCDs services and to ensure continuity of care. The learnings from COVID-19 pandemic such as public health communication, meaningful private sector engagement, community engagement and participation, legalisation of tele-consultations as well as the renewed interest of state governments in setting up community clinics should be effectively used. The increased availability, accessibility and affordability of CVDs and NCDs services through PHC system is the right approach and it will also help India to accelerate progress toward universal health coverage.

Disclaimer

CL is the staff member of the World Health Organization (WHO). The views in this article are personal, and do not necessarily represent the decisions, policy, or views of institutions/organizations, CL and other authors, which they have been affiliated at present or in the past.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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